Utilization Management Nurse Consultant - Remote

Position Summary

American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is seeking a dedicated Utilization Management (UM) Nurse Consultant to join our remote team.

Key Responsibilities

• Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification.
• Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information.
• Use established guidelines to authorize services or escalate to Medical Directors as needed.
• Navigate multiple computer systems efficiently while maintaining accurate documentation.
• Participate in occasional on-call rotations, including some weekends and holidays.

Required Qualifications

• Active unrestricted state Registered Nurse licensure in state of residence.
• Minimum 5 years of relevant experience in Nursing.
• At least 1 year of Utilization Management experience in concurrent review or prior authorization.
• Commitment to attend a mandatory 3-week training.

Education

• Associate's degree in nursing (RN) required, BSN preferred.